Hi.

All the above posts are interesting and relevant questions.

However, this patient case is screaming out to me as a classic active extension pattern. I will write quite strongly in this post only because i am almost 100% certain that i am right because i have seen this very same pattern many times before...

I do not think he has disc pain. I do not think AS.

From the sounds of it, i would be willing to bet he has overactive back extensors. He will tell you he is trying very hard to keep a "good posture". He will tell you that when he slouches, he feels better but it is "bad" for him to do so because you shouldn't slouch.

When he does his core exercises, i bet he is overactive in his posterior pelvic floor and finds it hard to do.

Active SLR with compression of his Wikipedia reference-linkSIJ will make his legs feel very heavy - while supine, get him to lift one straight leg up at a time and get him to note the "heaviness". Then use your fingers/hands via his PSIS and compress them medially and repeat. He will report significant heaviness in his legs.

The treatment solution is firstly to get through to him that he needs a lordosis and kyphosis in his body. He may be trying too hard to matintain good posture. He is probably overactivating his posterior pelvic floor and utilising his IO instead of TrA. He needs to learn to relax. You will probably find flexion-type exercises help, especially since it is the only movement that doesn't hurt.

He probably has a lot of fear of flexion due to his medical training and everyone worrying about discs etc but everything you have posted so far says that extension is painful - why put him into more extension when he stands with his hips hyper extended and flat backed?

Once his muscle overactivity comes down, you will see his extension pain decrease. Co-ordination and progression of his core stability work without IO/EO or RA activation will be important as well as relaxation of the posterior pelvic floor.

I am probably not making sense as it is midnight here but i will summarise.

1. He is probably suffering from excessive compression of the L/S. Utilise flexion-based exercises and stretches.
2. Tenderness in the facets, poor response to manual therapy (Maitland and mackenzie mobes) is classic for this condition.
3. The patient needs to get his head around the fact that he himself is making things worse by trying to maintain extension.
4. Restore normal spinal curves
5. Co-ordinate core-stability properly and specifically without the posterior pelvic floor.
6. Read Peter O'Sullivan's chapter in Grieve's Modern Manual Therapy or his Nov 2005 Masterclass article in Manual Therapy.
Link=www.sciencedirect.com/sci...e89ed9d8ae

I apologise for being so strong on this matter but I am almost 100% sure i am right...

Thanks for reading this far! I hope i didn't offend anyone.